Standard Companion Guide Health Care Claim …

1 2020 Copyright, CGS Administrators, LLC. Centers for Medicare & Medicaid Services (CMS) 7500 Security Blvd Baltimore, MD 21244-1850 Standard Companion Guide Health care Claim Payment/ advice (835) Based on ASC X12N implementation Guide , Version 005010X221A1 Companion Guide Version Number: June 2020 CMS 835 Version 005010 Companion Guide 2020 Copyright, CGS Administrators, LLC. ii CMS 835 Version 005010 Companion Guide 2020 Copyright, CGS Administrators, LLC. iii Disclosure Statement The Centers for Medicare & Medicaid Services (CMS) is committed to maintaining the integrity and security of Health care data in accordance with applicable laws and regulations.

2 Disclosure of Medicare claims is restricted under the provisions of the Privacy Act of 1974 and Health Insurance Portability and Accountability Act of 1996. This Companion Guide is to be used for conducting Medicare business only. CMS 835 Version 005010 Companion Guide 2020 Copyright, CGS Administrators, LLC. iv Preface This Companion Guide (CG) to the ASC X12N Technical Report Type 3 (TR3) Version 005010 and associated errata adopted under Health Insurance Portability and Accountability Act of 1996 (HIPAA) clarifies and specifies the data content when exchanging transactions electronically with Medicare. Transmissions based on this CG, used in tandem with the TR3, are compliant with both ASC X12N syntax and those guides.

3 This CG is intended to convey information that is within the framework of the TR3 adopted for use under HIPAA. This CG is not intended to convey information that in any way exceeds the requirements or usages of data expressed in the TR3. This CG contains instructions for electronic communications with the publishing entity, as well as supplemental information for creating transactions while ensuring compliance with the associated ASC X12N TR3s and the Council for Affordable Quality Healthcare Committee on Operating Rules for information Exchange (CAQH CORE) Companion Guide operating rules. In addition, this CG contains the information needed by Trading Partners to send and receive electronic data with the publishing entity, who is acting on behalf of CMS, including detailed instructions for submission of specific electronic transactions.

4 The instructional content is limited by ASC X12N s copyrights and Fair Use statement. CMS 835 Version 005010 Companion Guide 2020 Copyright, CGS Administrators, LLC. v Table of Contents Disclosure Statement .. iii Preface .. iv 1 Introduction .. 1 Scope .. 1 Overview .. 2 References .. 2 Additional information .. 3 2 Getting Started .. 3 Working Together .. 3 Trading Partner Registration .. 4 Trading Partner Certification and Testing Process .. 6 3 Testing and Certification Requirements .. 6 4 Connectivity / Communications .. 6 Process Flows .. 6 Transmission .. 6 Re-transmission Procedures.

5 7 Communication Protocol Specifications .. 7 Security Protocols and Passwords .. 7 5 Contact information .. 8 EDI Customer Service .. 8 EDI Technical Assistance .. 9 Trading Partner Service Number .. 9 Applicable Websites / Email .. 9 6 Control Segments Envelopes .. 9 ISA-IEA .. 11 GS-GE .. 11 ST-SE .. 11 7 Specific Business Rules .. 11 8 Acknowledgments and Reports .. 12 999 implementation Acknowledgment .. 12 9 Trading Partner Agreement .. 12 10 Transaction-Specific information .. 13 Header .. 13 Loop 1000A Payer Identification .. 13 CMS 835 Version 005010 Companion Guide 2020 Copyright, CGS Administrators, LLC.

6 Vi Loop 1000B Payee Identification .. 14 Detail Structures .. 14 Loop 2000 Header Number .. 14 Loop 2100 Claim Payment information .. 14 Loop 2110 Service Payment information .. 16 Summary .. 17 11 Appendices .. 17 implementation Checklist .. 17 Transmission Examples .. 18 Frequently Asked Questions .. 18 Acronym Listing .. 18 Change 20 CMS 835 Version 005010 Companion Guide 2020 Copyright, CGS Administrators, LLC. vii List of Tables Table 1 EDI Transactions and Code Set References .. 2 Table 2 Additional EDI Resources .. 3 Table 3 Control Segments / Envelope Requirements .. 9 Table 4 Detail Structures Business Rules and Limitations.

7 12 Table 5 Header Specific 13 Table 6 Loop 1000A Payer Identification .. 13 Table 7 Loop 1000B Payee Identification .. 14 Table 8 Loop 2000 Header Number .. 14 Table 9 Loop 2100 Claim Payment information .. 14 Table 10 Loop 2110 Service Payment information .. 16 Table 11 Summary Specific Requirements .. 17 Table 12 Acronym List .. 18 Table 13 Companion Guide Version History .. 20 CMS 835 Version 005010 Companion Guide 2020 Copyright, CGS Administrators, LLC. 1 1 Introduction This document is intended to provide information from the author of this Guide to Trading Partners to give them the information they need to exchange Electronic Data Interchange (EDI) data with the author.

8 This includes information about registration, testing, support, and specific information about control record setup. An EDI Trading Partner is defined as any Medicare customer ( , provider/supplier, billing service, clearinghouse, or software vendor) that transmits to, or receives electronic data from Medicare. Medicare s EDI transaction system supports transactions adopted under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) as well as additional supporting transactions as described in this Guide . Medicare Fee-For-Service (FFS) is publishing this Companion Guide (CG) to clarify, supplement and further define specific data content requirements to be used in conjunction with, and not in place of, the ASC X12N Technical Report Type 3 (TR3) Version 005010 for all transactions mandated by HIPAA and/or adopted by Medicare FFS for EDI.

9 This CG provides communication, connectivity, and transaction-specific information to Medicare FFS Trading Partners and serves as the authoritative source for Medicare FFS-specific EDI protocols. Additional information on Medicare FFS EDI practices are referenced within Internet-only Manual (IOM) Pub. 100-04 Medicare Claims Processing Manual: Chapter 22 - Remittance advice can be accessed at Chapter 24 - General EDI and EDI Support, Requirements, Electronic Claims, and Mandatory Electronic Filing of Medicare Claims. This document can be accessed at Scope EDI addresses how Trading Partners exchange professional and institutional claims, Claim acknowledgments, Claim remittance advice , Claim status inquiry and responses, and eligibility inquiry and responses electronically with Medicare.

10 This CG also applies to ASC X12N 835 transactions that are being exchanged with Medicare by third parties such as clearinghouses, billing services, or network service vendors. This CG provides technical and connectivity specification for the 835 Health care Claim : Payment/ advice transaction Version 005010. CMS 835 Version 005010 Companion Guide 2020 Copyright, CGS Administrators, LLC. 2 Overview This CG includes information needed to commence and maintain communication exchange with Medicare. In addition, this CG has been written to assist you in designing and implementing the ASC X12N 835 transaction standards to meet Medicare's processing standards.